How Much of Yourself Can You Give to Others?

I have been practicing general internal medicine for over 35 years in the same community. I have many patients who started with me in 1979 and are now in their late eighties to early nineties.  Predictably and sadly they are failing.  Not a week goes by without one or two of them moving from general medical care to palliative care, very often with the involvement of Hospice for end of life care.   Medicare may now compensate for discussion of end of life issues but anyone practicing general internal medicine or family practice has been discussing end of life issues appropriately for years with no compensation. It just comes with the territory.

Most of us still practicing primary care thrive on being able to improve our patient’s quality of life and our major compensation can be hearing about their interactions and social engagements with family and friends.  It is an accomplishment to see you’re 90 year old with multisystem disease for years, dance at her great grandchild’s wedding.  No one who cares for patients longitudinally for years is that dispassionate that they do not give up a piece of their heart and soul each time they lose a patient or have one take a turn for the worse.   When I lose a patient, if time permits, I will attend the funeral or family grieving gathering during the mourning period.  Everyone gets a personal hand written letter. Completion of the circle of life and then moving on is part of the process.

I think physicians’ families take the brunt of this caring and I am sure mine does. As much as you want to have time and patience and sympathy and empathy for your loved ones, the work truly drains your tank and reserve. When you answer the questions of the elderly and their families over and over, often the same questions, it drains you.  Unfortunately, I believe my elderly failing mother is cheated the most by this process. Last weekend when making my weekly visit she was complaining again about the same things, asking the same questions that have repeatedly and compassionately been addressed by my brother and I. My wife interjected that I sounded angry and annoyed. I was. I told her that unfortunately all the compassion and understanding in me had been drained already today and I needed time to recharge.

I saw the widow of a patient who expired last month in his nineties. I had offered to make home visits and they were declined several times by the patient and his spouse. His last week of life he asked to receive Hospice care and they assumed his care.  I called the surviving spouse and wrote what I considered a personal letter of condolence.  His wife told me she was disappointed in me for not coming up to see him one last time. I apologized for not meeting their needs but wondered inwardly, how much can I give and still have something left for myself and my loved ones?

There is No Hope for Ending Medicare Fraud

South Florida is apparently a hotbed for criminal Medicare fraud. It is easy theft with crime rings accessing Medicare numbers of the elderly in Dade County and Broward and setting up durable medical equipment companies that bill our local Medicare subsidiary for equipment that doesn’t exist. Having said that, yesterday I received a Medicare Summary of Benefits letter for my mother at my home. She is almost 90 years old and my brother and I are her legal guardians and handle all her financial affairs while she resides in a skilled nursing facility in northern Palm Beach County, Florida. We moved her to this excellent campus in May of 2015 from a facility in Broward County and by submitting a change of address notice to the US Post Office, all her mail now comes to me. The official Medicare Benefits Summary stated that on September 11, 2015 a claim had been received for a wheelchair for my mom for $280 from a durable medical equipment company in Miami, Florida. The ordering physician was her former physician at her former Broward County skilled nursing facility. I thought it was strange that a bill would be submitted for a wheelchair four months after she was gone from that facility so I tried to reach the doctor. I was told that he was no longer at that facility. I next called my mom and asked her if she had received a new wheelchair in the last few months and she just did not remember if she had or not. I had no knowledge of it but the move from one facility to another accompanied by closing down her apartment in the assisted living section had been tumultuous and disorderly.

I then called the Medicare Fraud number listed on the piece of mail, 1-800- Medicare. The call was answered by an automated attendant who did not list “Fraud Report” as one of the choices so I pressed 5 for “other.” I was placed on hold for five minutes and a pleasant gentleman asked me why I was calling. I explained and he politely asked me to please hold on. Another five minutes elapsed before he got back on the line and apologized for the delay. He started asking me personal questions about my mother for security purposes such as her address, phone number, date of birth, Medicare number. He then asked me to hold on while he prepared a report and another seven minutes elapsed. He told me he would be transferring my call to a supervisory claims officer and I held on again.

It took five or more minutes before a woman got on the phone and repeated the same questions I had already been asked and answered. I tried to explain the purpose of the call and my relationship to my mother but she politely silenced me and told me that she had the original agent’s summary and knew the reason for the call. She asked me to hold on while she looked up the claim and another ten minutes elapsed. When she returned she told me that Medicare paid durable medical equipment claims monthly for up to twelve months and possibly this was a late claim for a 13th month. I then asked her what type of non-motorized wheelchair could possibly cost 12 X $280. I explained to her that all I was interested in was reporting a suspicious claim. She told me that without me forwarding her a copy of my Power of Attorney form she would not be able to reveal any claims history information to me. I told her I wasn’t asking for her to reveal any information but was just trying to report a suspicious Medicare claim. She responded that the claim had been denied and not paid so why was I making such a fuss in the first place. Having invested almost an hour trying to be a responsible citizen I gave up. If this is the type of system we as citizens put in place and tolerate then we deserve to be ripped off!

2015 Changes in Medicine for Medicare Patients

CMS, the parent organization for the Medicare program has decided to reduce health care costs. One method for reducing health care costs is to pay a flat bundled fee for services to one entity and let that entity worry about how to pay for all the services and equipment. CMS first venture into this practice in the State of Florida begins shortly with Medicare deciding to pay one flat fee for knee and hip replacements. In our local area they will pay Boca Raton Regional Hospital (BRRH) one time. The hospital is expected to provide physicians, nurses, pharmaceutical goods, the orthopedic appliance (the hip and knee) and all related costs including your postoperative stay in a rehabilitation facility and physical therapy. If a patient has a medical complication of the surgery, or the surgeon needs consultative physician assistance, that too is covered in the bundled fee.

This means that your orthopedic surgeon will either need to be an employee of Boca Raton Regional Hospital or a contracted physician at an agreed upon price for that service. For several years now, CMS has been encouraging hospitals and health care organizations to organize into Accountable Care Organizations (ACO’s) which would receive the bundled payments and distribute them according to a formula they devise internally. The ACO’s have formed in most parts of the country, but Florida remains as a stronghold of fiercely independent physicians primarily in the medical and surgical specialties that are procedure oriented and generate large revenue streams. They have seen hospital systems like Boca Raton Regional Hospital purchase physician practices and try to run them at least twice in the last 25 years. In each case the hospitals lost large sums of money, the practices ran inefficiently and were returned to the physician owners as a means of cutting their losses. Over the last few years, in addition to building many new facilities , BRRH has been buying up local physician practices and employing the doctors in primary care ( Boca Care), hematology oncology ( Lynn Regional Cancer Group), plus their hospitalist service, emergency department physicians ( who additionally staff their community Urgent Care Centers) pathologists , anesthesiologists and others. By accumulating so many of the formerly private physicians’ as employees or contracted help, they were able to change the structure and bylaws of the medical staff rules and regulations and bylaws allowing the hospital administration to effectively eliminate a checks and balances arm of decision making that protected patient and physician interests.

When you enter the hospital for a knee or hip replacement, it is unclear if your personal physician will be paid by Medicare for seeing you if that physician is not a member of the Accountable Care Organization or an employee of the hospital. A non-employed, non-contracted consulting doctor may possibly bill the patient privately for their services but it is unclear whether Medicare will pay the doctor if they accept assignment, or reimburse the patient if they pay privately and submit the receipt to their insurances for reimbursement. CMS plans to bundle payments for 30% of existing conditions by 2017 and over 70% by 2023. These changes are part of the Affordable Care Act or “ObamaCare”.

I will continue to see my patients who need a hip or knee replacement and develop a fair payment option for them. This will apply to any future bundled service CMS implements as well. My patients will continue to be cared for by me! Experienced local physicians have a healthy distrust of the hospital as an employer based on their past track record. Younger physicians coming out of training with large educational debt and a desire to balance their lives by working regular shifts are more willing to accept employment positions and work for the ACO’s. The goal of the Federal Government is to reduce health care spending by fiat rather than by natural market forces. As the Baby Boomers age and develop more chronic conditions and require more care It seems to me that physicians will need to spend more time with these complex patients rather than less time in short conveyor belt type visits being advocated CMS and current health care policy makers. Feel free to contact me if you wish to discuss any of this.

Addendum: “Why You Can Not Find a Doctor to Accept Medicare”

Center for Medicare ServicesOn April 14, 2015 the Senate, having returned from a recess, voted to repeal the SGR initiative thus halting a proposed 21% minimum payment reduction to health care providers (physicians). Under the new legislation sent to President Obama for approval, doctors will receive between a 0.5% to 1% annual increase in reimbursement through 2019. The measure proposes alternative pay structures which are designed to reduce overall health care costs and rate of health care cost growth. They involve paying one large entity which would then dole out pre-negotiated payments to its members delivering the services.

The American Medical Association as well as specialty medical and health groups are hailing this as a major victory for doctors and patients. I see it a bit differently.

Since 1977 the Congress of the United States has held practitioners at loaded gun point always threatening to reduce physician reimbursement without reducing physician costs or bureaucratic burdens in the least. Generations of policy advisors and elected officials have created a level of mistrust and uncertainty between themselves and providers while always painting the health care delivery teams as greedy money craving individuals more interested in their personal gain than the health of their patients. The result is that for years doctors have left the Medicare system and or retired early.

The current annual increase of up to one percent is accompanied by additional bureaucratic requirements having little or nothing to do with the doctor patient relationship. One percent will not keep up with the cost of inflation or the additional costs involved to meet the bureaucratic new requirements of CMS and policy wonks.

To hail this as a victory is like trying to sell Custer’s last stand at the Little Big Horn as a victory for the US Cavalry. The net result will be the destruction of small private practices, the growth of concierge medicine and the growth of enormous conveyor built corporate medical groups where patients are a product not a human individual.

Why You Can Not Find a Physician Who Accepts Medicare

CMSSGR (sustained growth rate) is a policy and law put in place by the U.S. Congress signed into law four Presidential administrations ago and kept in place year after year by our non-creative elected Federal officials. It was designed to keep the costs of health care growth down by reducing payments to providers if they exceeded the health spending budget for the previous fiscal year. The problem is that health care spending has climbed continuously and it has never stayed within the budgetary guidelines legislated by Congress.

After the first year of the law the General Accounting Office noted an 8% increase in health care spending above the budgeted amount. Congress was supposed to reduce health care payments to providers by 8% the next year, but the providers howled about an 8% reduction and the President and the Congress backed down. Instead of a reduction they gave providers a cost of living increase. The GAO showed that the increased spending was not due to physician pay increases or physician generated costs but due to increased usage and expense in areas outside provider control. Every subsequent year since the SGR became law, the Congress has backed down and granted a miniscule increase instead. The difference between what was budgeted and what was actually spent has accumulated from year to year and each subsequent Presidential administration and U.S. Congress has been reluctant to correct the SGR because the monetary difference would appear on their administration’s balance sheet and legacy. That continued until the Affordable Health Care Act (Obama Care) passed and signed into law before anyone who voted on it actually read it, made correcting the SGR part of the law.

On January 1, 2013 the SGR was due to be repealed by Congress and health care providers were due to receive an 18%- 45% reduction in fees for services. Congress kicked the can down the block until January 1, 2014 and again until December 31, 2014 when Obama Care made the reduction mandatory. The last Congress kicked the issue down the road until April 15, 2015. They were supposed to settle the issue before their spring recess but they adjourned for the spring recess with promises of passing new legislation upon their return on Monday April 13, 2015. That was yesterday when Conservative Republicans announced that after two weeks of consideration they had major problems with provisions of the legislation they had agreed to pass before their spring recess. Their delay will go beyond April 15th.

The Centers for Medicare Services or CMS decided simply to not process any bills or make any payments to health care providers until Congress makes up its mind. Since April 1st they have paid no one except themselves. If no legislation is agreed upon by midnight tonight, CMS will begin processing payments to providers retroactively to April 1, 2015 with a minimum 21% reduction in fees compared to the 2014 payment rates. Physicians are reacting just as expected. Many have decided to no longer see Medicare patients. Those that do see Medicare patients will require payment for services by cash or credit card at the time of service with payments up to 115% of the 2014 Medicare allowable rate for that service. Many will leave the Medicare system entirely.

Our office will continue to see Medicare patients at the current time under the existing payment systems and we will give this Congress an opportunity to fix the problem. When we refer you to specialty physicians we have no way of knowing who will be seeing Medicare patients and who will not. We suggest you ask that particular office before your planned visit so there are no surprises at the check in check out window.

Medical Costs Rise as Retirees Winter in Florida

Healthcare CostsIn the January 31, 2015 edition of the NY Times, Elisabeth Rosenthal writes about the high numbers of tests performed on seasonal visitors to the state of Florida in the winter (as if seasonal visitors to Florida requiring health care are a new phenomenon). She cites a NY Times analysis of Medicare data released for 2012 showing twice the number of nuclear stress tests, echocardiograms and vascular ultrasounds for Medicare beneficiaries in Florida than in Massachusetts. She blames it on Florida cardiologists purchasing medical testing equipment for their offices and doing a large volume of tests to recover much of the income lost to a drop in reimbursement rates by Medicare to doctors for actually seeing patients, examining them and providing care. The article then goes on to discuss the increased number of tests in Florida in the last two years of a patient’s life compared to other areas of the country. She does admit that senior citizen rich population centers in NY, California, Arizona, South Texas and South Nevada have similar data showing high rates of testing than the rest of the country, but this is passed off as an afterthought. There are then a slew of anecdotal stories about individuals advised to undergo a procedure or test who declined and recovered nicely without it being done.

I have a suggestion for the NY Times, New York magazine and all the online purveyors of pearls of wisdom on health care. Suggest that your readers vacationing in Florida for the winter find a primary care physician (PCP). Find one who is willing to review the patients’ medical records from their northern physician and share clinical decision making on important issues with the physician(s) who know them longest and best.

For many years these prestigious periodicals have been suggesting that the patients’ only see a specialist. If the patients do not self-refer themselves to a specialist, their children often self-refer them to a specialist. Most specialty physicians are ethical, moral practitioners not churning out tests for self-profit. You can avoid the ones over utilizing at your expense by finding a well-trained internist or family practitioner who has no x-ray suite in the office, no nuclear stress testing equipment, no echocardiogram machines and no extensive in house laboratory. You probably won’t find that type of doctor if your physician is an employee of a hospital based health care system or Accountable Care Organization where the facility fee and incentives to over utilize are very strong. You won’t find that if you use the Emergency Room or a walk in center as your primary care physician because the same incentives exist.

You can find this dying breed of physician (dying because Medicare reimbursement for their services and influential periodicals have driven them out of existence) by calling the local county medical society or the local hospital medical staff offices and asking for a board certified internist or family practitioner who is not employed by the hospital or one of its large health care systems.

Consider a concierge or direct pay practice as well. The customer services in those practices, and additional patient time the doctors have, allows them to get the full story and communicate with those doctors who know you best rather than just shuffle you off for tests.  After all, time is the essence of quality, especially when it comes to healthcare.

Medicare Part D Open Enrollment For 2015

MedicareFrom October 15, 2014 through December 14, 2014 Medicare beneficiaries will have an opportunity to choose their 2015 prescription drug plan. These plans change annually. If you do nothing you will remain in your current plan in 2015 even though the price will change and the drugs covered will change.

On your computer go to http://www.medicare.gov . Choose prescription drug plans. You will be asked to put in your name, your Medicare ID number and your zip code. They will ask you to enter your favorite pharmacy and then all your medications by name, dosage and frequency of administration. You will then run the program and it will suggest the best plan for you. I suggest you choose the least expensive plan. There are elective add on features which pay your drug deductible and even cover the donut hole for a higher fee.

If you have any questions feel free to call us. If you cannot use a computer and need our help please let us know.

Medicare Payment Figures Released

Center for Medicare ServicesThe Center for Medicare Services (CMS) parent organization of the Medicare program, released detailed raw data showing how much providers of Medicare services are paid. For many years, hospitals and physician organizations have battled to keep this information private from the media, the public and private health insurance companies. As a citizen I have no problem with transparency, but if in fact we are asked to show our payments from Medicare then I believe every other individual and business
should be required to have their federal payments revealed to the public and media as well.

The data revealed that a physician in West Palm Beach, who treats diseases of the eyes in the elderly, received 21 million dollars from Medicare during the time period reviewed, leading the country in individual payments. That physician claims that most of the payment was for a drug called Lucentis injected into the eyes of seniors with macular degeneration a potentially sight ending disease. The problem is that other experts claim that a less expensive drug, injected into the eye produces equal or better results for far less cost. If the less expensive drug produces equal or better results then why is Medicare still paying for Lucentis, except in cases where the patient is allergic to the cheaper alternative or where it has not worked? CMS has the ability to control its payments for ineffective products. It just chooses not to do so. The NY Times made a big splash headline of the fact that this physician made a sizeable political contribution to a political party and then asked elected officials to look into why he was being singled out for repeated Medicare audits? Yes Medicare has the right to review each chart and determine if the treatment was indicated, if it was provided, if it was documented and then billed per their extensive rules and regulations. CMS makes the rules. If the physician follows those rules then it is inappropriate to slander him and accuse him and ask the tabloids to do what CMS could not do because the physician was in fact playing by their rules!

At the same time that CMS released this data, organized crime continues to profit from Medicare fraud in south Florida, particularly in Dade and Broward Counties because it is less risky to commit Medicare fraud than it is to run drugs, prostitution, human trafficking and loan sharking. Maybe CMS should be trying to stop the flow of low hanging criminal fraud rather than releasing data on provider payment. As the storm clouds gather over the use of this data, ObamaCare seems to have reached its enrollment goals despite major startup problems. Despite this, Kathleen Sebellius, the CMS director resigned. Do you think it had something to do with the inappropriateness of the payment data release and the ultimate consequences?

The Business of Medicine Should Not and Can Not Replace Care and Compassion

Compassionate CareWell over a year ago I advised my 80 something year old patient and her children that due to progression of her Parkinson’s disease, and her frail nature, she needed a higher level of assistance and care if she wished to remain in her home.  She was extremely unsteady walking and several courses of physical therapy had not improved the situation. The patient was feisty and would only allow help to come for 4 hours per day despite having a long term care policy that paid for significantly more.  She lost her balance recently, fell and landed on her back. She could not get up or get to a phone or her alert bracelet and was found seven hours later on the floor by her aide arriving for work.  In the Emergency Room x-rays revealed several acute fractures of her vertebrae that accounted for her severe pain with movement and inability to stand, bear weight or walk.

I hustled over to the ER and examined her and called the interventional radiologist to see if he could perform a procedure called a kyphoplasty that would cement the fractures and remove the pain. It was early Friday afternoon and the traditional back specialists were unavailable until the next day.  The radiologist came promptly, was professional and very pleasant explaining that he could do the procedure but because she took a baby aspirin for prevention of stroke, he would not perform it until the aspirin wore off in 5 – 7 days because of fear of excessive bleeding around the spinal cord.  He suggested we send her home with pain medications and round the clock assistance or keep her in the hospital until the aspirin wore off and he felt comfortable performing the procedure.  He was courteous and a credit to any profession. 

Since the patient was in great pain with any movement, I chose to admit her to the hospital while we sorted things out.  I admitted her as an inpatient because she is extremely elderly and frail with medical conditions that led to this injury which an expert had just told me required surgery to fix. She could not walk or transfer to a chair or wheelchair to get food, water or get to the bathroom. She had no arrangements for additional help at home to assist her. She could not, in my professional opinion, go home safely at this point.  

The next day I was making rounds late in the day for me at noon, reviewing the situation with the patient and her son when the physician’s assistant (PA) for the back surgeons, Andy, walked in and introduced himself. They had not seen her Friday evening or Saturday morning and this was their first contact with the patient.  My consult request and phone call had been quite clear. I wanted to know how they viewed the injury and what options did they feel were best to fix the problem. I additionally asked them how their approach would differ, if at all, from the approach of interventional radiology.  I had seen Andy around the facility and said “hello” but never formally met him so it was an introduction for me as well. 

“Hi, my name is Andy, and I work for Doctors Y and Z.  We have a little problem with your insurance.  You have a Medicare Advantage plan and we are not part of that plan. Most of the time, about 95% of the time, we eventually get paid for our services but we need to know how we will get paid for performing a procedure on you to fix your back before we proceed further. In these situations we usually ask the patient to pay the bill up front ($1000 – $1200) and then we submit the charges to your insurance company. If we get reimbursed from the insurance we return the money to you.”  

I took a deep breath and wondered if maybe I was overreacting to the brusque inappropriate presentation to a groggy senior who had been given a narcotic 30 minutes before for pain and was really in no condition to listen to any presentation or sign away informed consent.  I cut Andy off in the middle of a sentence and reminded him that I had requested an opinion. The son, an attorney by trade took up the fight and reminded the PA just how inappropriate his initial remarks were and that in this case money was not a problem but the manner of dealing with an elderly confused patient was.  I played mediator at this point and got the PA to explain that his employers had done several thousand of these procedures and handled many more complications than most interventional radiologists and that their success record spoke for itself.  He outlined a slightly different approach and once we got him talking about the reasons for his invitation onto the case, justified calling his group.

I am all in favor of physicians being paid for their professional services. This could have been handled differently by calling me first and informing me that they had concerns about payment and insurance and letting me address the issues. It could have been handled far gentler by answering the questions asked first and suggesting options and then reviewing the problems with the insurance. Had the gentleman performed a history and or exam rather than rely on the ER PA’s evaluation the day before, he would have seen that the patient was not in a position to comprehend what he was saying or sign for a procedure.  

This is not a criticism of PA’s or Nurse Practitioners. It is a criticism of any practitioner who does not answer the questions asked by the referring physician or question the referring physician about payment before arriving for the consult if they have questions about getting paid for their time and expertise.

The post script is that the son wisely chose to use this group based on their talents and experience and put aside the rude and insensitive communication by the PA. The surgery went well and the patient will go home after spending three nights in the hospital. 

There is still one obstacle to overcome. The hospital ignored my written order to make her status inpatient and made her status observation which will prevent her from receiving any post-surgery therapy or care which is paid for by her insurance. I will fix that. Keeping the phone number on my phone contact list of the Office of the Inspector General who investigates Medicare irregularities opens doors in situations like this. It does not change the fact however that as practitioners we need to be much more thoughtful when we discuss financial issues before medical issues if we wish to continue to be considered a profession rather than another business.

Medicare Part D – Who Is Watching the Henhouse?

Medicare MontageOctober through December 7th is the time of year when patients should be re-evaluating their Medicare Part D Drug Plan and their private insurance options.  Medicare patients are encouraged to log on to www.medicare.gov and access prescription drug plans. They are asked to enter their Medicare identification number, zip code, name and then their prescription medications. The computer will then find them the most cost effective drug plan in their area for their medication needs. 

This process is so important that I always remind my patients about it in our practice quarterly newsletter and offer to perform the service for those patients who are not computer literate or who just do not get it. It is additionally the time of year when patients begin to receive notification that some of the medications covered on their Medicare Part D Prescription Plan formulary, or on their private plans, will not be covered the next year and they will need to change. 

This is not a particularly difficult action for younger healthier patients taking few prescription drugs but it does become challenging for the elderly on multiple medications for many chronic diseases and problems. There is no organization or government office supervising or monitoring this process and it can lead to problems. Take the example of TJ, an 84 year old woman with long term sleep problems, coronary artery disease, intermittent congestive heart failure, chronic kidney disease, high blood pressure , elevated cholesterol, spinal stenosis, diffuse osteoarthritis and age appropriate short term memory loss. After seeing a neurologist she has been placed on temazepam 15 mg one half tablet at bedtime as needed for sleep. She purchased a Medicare Part D Prescription Drug Plan through AARP because of her trust in that organization.  They contract with United Healthcare to provide the Medicare Part D Drug Insurance Plan. 

In 2013 a 30 day supply of temazepam cost the patient $10 per month. The notice says that in 2014 that same medication will cost the patient $85/month if she buys the generic version or $95 per month if she wishes to purchase the brand name version. Her AARP United Healthcare is suggesting that in 2014 she switch from temazepam to trazodone.  Trazodone will only cost her $7 per month for the generic version. Trazodone is an antidepressant drug which was found to be sedating and has now obtained permission to be used for insomnia.  In my humble opinion comparing one half of a 15 mg temazepam to 50 mg of trazodone for sleep is like comparing a small ceremonial glass of wine consumed at a religious service to snorting a few lines of cocaine (a stimulant), and then taking a few shots of vodka to slow the shakes of your hands before you go out and drive carpool.

Our small office caught this error in judgment and prevented the change. We wonder who exactly at the drug plan considered the difference in medications in this senior citizen and approved this?  How much money, favors or gifts exchanged hands at the purchasing and corporate level to negotiate this change in formulary.  If this patient was in a larger practice with little oversight would this change in medications been handled and approved by non-medical staff with no questions asked? 

Patients who put their trust and faith in AARP deserve better oversight and regulation.  This is one case but how many thousands more are slipping through in the name of greed and corporate profits?